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Functional Surgery for Malignant Subungual Tumors: A Case Series and Literature Review
Cirugía funcional en tumores malignos subungueales. Serie de casos y revisión de la literatura
M. Flores-Terry, G. Romero-Aguilera
, C. Mendoza, M. Franco, P. Cortina, M. Garcia-Arpa, L. Gonzalez-Ruiz, J.A. Garrido
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Servicio de Dermatología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
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Flores-Terry, G. Romero-Aguilera, C. Mendoza, M. Franco, P. Cortina, M. Garcia-Arpa, L. Gonzalez-Ruiz, J.A. Garrido" "autores" => array:8 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Flores-Terry" ] 1 => array:4 [ "nombre" => "G." "apellidos" => "Romero-Aguilera" "email" => array:1 [ 0 => "gromeroa@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Mendoza" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Franco" ] 4 => array:2 [ "nombre" => "P." "apellidos" => "Cortina" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Garcia-Arpa" ] 6 => array:2 [ "nombre" => "L." "apellidos" => "Gonzalez-Ruiz" ] 7 => array:2 [ "nombre" => "J.A." "apellidos" => "Garrido" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cirugía funcional en tumores malignos subungueales. Serie de casos y revisión de la literatura" ] ] "resumenGrafico" => array:2 [ "original" => 1 "multimedia" => array:5 [ "identificador" => "fig0035" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 797 "Ancho" => 1333 "Tamanyo" => 104944 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Malignant subungual tumors (MSUTs), which largely comprise subungual squamous cell carcinoma (SUSCC) and subungual melanoma (SUM), are uncommon tumors in which early diagnosis and adequate surgical management are essential.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> Traditionally, dermatologists used to refer patients with MSUTs to a traumatologist or plastic surgeon for more or less aggressive amputation.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">2</span></a> While amputation achieves good local control, it leaves a considerable functional and cosmetic defect, particularly in the case of finger lesions. Just over 10 years ago, functional surgery consisting of wide local excision (WLE) of the nail unit emerged as an alternative to amputation.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">3,4</span></a> This technique may offer effective control for noninvasive MSUTs and even for larger tumors without other poor prognostic factors.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a> WLE of the nail unit preserves the function of the distal phalanx and, compared with amputation, achieves better cosmetic outcomes<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a> without modifying prognosis. In this study, we present a series of MSUTs treated with WLE of the nail unit at our hospital over a 10-year period (2008-2017), describe the surgical technique, and review its indications.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material and Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients</span><p id="par0010" class="elsevierStylePara elsevierViewall">We undertook a retrospective observational study of the surgical management of patients diagnosed with MSUTs at the Dermatology Department of Hospital General Universitario de Ciudad Real (HGUCR) in Ciudad Real, Spain over a period of 10 years (July 2008 to June 2017). We analyzed demographic, clinical, and histopathologic variables, disease stage at diagnosis, and outcomes (recurrence, metastasis, and death). A survey was designed to collect information on procedure-related complications not reflected in the patients’ charts, postoperative sequelae, and level of patient satisfaction assessed on a Likert scale. The study was approved by the research committee at the HGUCR and complied with regulations governing the publication of patient data. Consent was obtained from all patients.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">WLE of the Nail Unit: Surgical Technique (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1-3</a>)</span><p id="par0015" class="elsevierStylePara elsevierViewall">En bloc excision of the nail unit was performed using the procedure described below after confirmation of the diagnosis by biopsy.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">3,7</span></a> The procedure is performed under a digital nerve block and hemostasis is achieved with a tourniquet. A margin of 5<span class="elsevierStyleHsp" style=""></span>mm is marked around the nail plate or, when the clinical lesion extends beyond the plate, around the lesion to ensure complete excision. Dermoscopy can help to define the extension of the lesion. Using a #15-blade scalpel, a vertical incision is made down to the periosteum, dissecting the subungual region including the entire nail plate, the lateral and proximal folds, the germinal matrix, and the nail bed. Deep dissection is performed at the level of the underlying periosteum, but the periosteum is spared to prevent damage to the extensor tendon at the point of insertion into the base of the distal phalanx. The excised specimen is oriented appropriately and marked with a silk suture for detailed histopathologic examination. After removal of the tourniquet, the wound is irrigated with normal saline solution and conservative hemostasis is achieved. This procedure leaves a quadrangular defect, which can be reduced in size by dividing the vertical septa, allowing the soft tissue to be advanced circumferentially and dorsally (paronychial flap advancement); additional advancement is made possible by sutures at the 4 corners (Figs. 2 & 3), reducing the size of the surgical defect even further. The rest of the defect is reconstructed using a regeneration template and closed with a full-thickness skin graft (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1-3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Review of the Literature</span><p id="par0020" class="elsevierStylePara elsevierViewall">We performed a search in PubMed for articles on the surgical management of MSUTs with function-sparing (functional/wide local) surgery using the following search terms: <span class="elsevierStyleItalic">malignant subungual tumors</span>, <span class="elsevierStyleItalic">subungual melanoma</span>, <span class="elsevierStyleItalic">subungual squamous cell carcinoma</span>, <span class="elsevierStyleItalic">functional surgery</span>, and/or <span class="elsevierStyleItalic">wide local excision in subungual tumors</span>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The inclusion criteria were original studies containing full evaluations of at least 4 SUMs and/or SUSCCs treated with functional surgery consisting of WLE or variants in addition to information on tumor thickness (Breslow depth) and outcomes (recurrence and mortality) over a minimum follow-up period of 2 years.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">Over the 10-year period, 11 MSUTs (7 SUMs and 4 SUSCCs) were excised from 5 women and 6 men, all white, aged between 45 and 81 years (mean age, 61 years). The clinical characteristics of the patients (<a class="elsevierStyleCrossRefs" href="#fig0020">Figs. 4 and 5</a>) and the excised tumors are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Mean time from onset of symptoms to diagnosis was 35.1 months (range, 6-120 months). This time was similar for SUMs (37.1 months) and SUSCCs (31.5 months). Diagnosis was confirmed by biopsy in all cases, and the 4 patients with SUSCC additionally underwent bone radiography, which was normal in all cases.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Two of the 11 patients had invasive melanoma and underwent amputation. The other 9 underwent WLE of the nail unit with 5-mm margins and deep excision above the periosteum (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1-3</a>) followed by repair of the surgical defect with a full skin graft, as described in the methods section. Just 1 tumor had surgical margins that needed to be extended after histology showed marginal disease.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The clinical and imaging studies performed after surgery showed local disease in all cases. Polymerase chain reaction detection of human papillomavirus, performed in all patients with SUSCC, yielded 1 positive result.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Mean follow-up time was 39 months (range, 12-96 months). During this period, no local or regional recurrences were observed. One of the patients who had undergone amputation (patient #3) developed brain metastasis and died 31 months after diagnosis of the primary tumor.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Surgical complications included wound infection (3/11), subungual spicules (1/11), moderate stiffness (requiring physiotherapy) that affected the distal interphalangeal joint of a finger (1/11), hypersensitivity to cold (3/11), hypersensitivity to minor trauma (4/11), mild loss of fine-touch sensation (picking up/grasping small objects) in 3 of the 4 patients with finger nail involvement, and reactive hyperkeratosis in 1 patient who had undergone surgery of the first toe. All the complications were mild and transient and improved or practically disappeared over the 1-year follow-up period. Level of patient satisfaction was good and the impact on quality of life was minimal.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The results of the literature search conducted in PubMed in December 2017 are shown in the flow chart in <a class="elsevierStyleCrossRef" href="#fig0030">Figure 6</a>. The resulting evidence for functional surgery with WLE in SUM and SUSSC is summarized in <a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>.</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Our findings (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) and the results of the literature review (<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>) indicate that functional surgery consisting of WLE of the nail unit is a good alternative to amputation in MSUTs, as it is associated with low recurrence (<<span class="elsevierStyleHsp" style=""></span>7%) and better functional and cosmetic results. WLE is associated with high patient satisfaction, good local disease control, and no differences in survival.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The nail unit is a complex structure that can be affected by a wide range of benign and malignant tumors.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> MSUTs are uncommon and mainly consist of SUSCC and SUM. Both of these entities have variable clinical presentations and require a high level of suspicion to prevent diagnostic delays, which can complicate treatment and negatively affect prognosis.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6,7</span></a> Because MSUTs are rare, there is little evidence on the best treatment strategies, and exhaustive literature reviews are thus necessary to identify the best available evidence.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">21</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">SCC is the most common MSUT. SUSCC affects middle-aged men and is more common on the hands.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6,9,22</span></a> It can mimic benign conditions, causing diagnostic delays. Similar conditions include onychomycosis, nail dystrophy induced by trauma or inflammatory disease, exostosis, verruca vulgaris, pyogenic granuloma, and chronic paronychia.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6,23</span></a> Metastasis and mortality are rare in SUSCC.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The second most common MSUT is melanoma. SUM is rare in whites, in whom it accounts for just 2% to 3% of all melanomas.<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">24,25</span></a> It is common, however, in patients with high Fitzpatrick skin types. In blacks and Asians, for example, it represents 20% of all melanomas.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5,11</span></a> It affects both men and women starting in the fifth decade of life, and is more common in the first fingers and toes. Early presentations include irregular pigmented bands; later manifestations include the Hutchinson sign and, once advanced disease has set in, dystrophic nail changes. Lesions may also be amelanotic, however, resulting in diagnostic delays.<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">25,26</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Subungual disease is a risk factor in malignant melanoma, but it is not clear whether this is because the tumor is diagnosed later<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11,25</span></a> or because it is biologically more aggressive.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a> Nail keratin increases the dispersal of light in melanocytic lesions, causing what is known as the <span class="elsevierStyleItalic">Tyndall effect</span>,<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">21</span></a> and this can makes it more difficult to classify lesions. Mean time to diagnosis is very long in these patients. In our series, the mean time from the onset of symptoms to diagnosis was 35 months. Mean Breslow depth was 1.16<span class="elsevierStyleHsp" style=""></span>mm; 4 of the 7 tumors (57%) were in situ but 2 (28%) had a Breslow depth of over 3.8<span class="elsevierStyleHsp" style=""></span>mm. Similar data have been observed in other studies, which have reported prevalence rates of 18% to 25% for SUM in situ,<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11,24</span></a> albeit with a high rate of thick melanomas (29%-50% measuring ><span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>mm).<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11,24,25</span></a> Factors linked to high mortality in SUM are similar to those seen in malignant melanoma in nonacral locations: Breslow depth, ulceration, a positive sentinel lymph node biopsy, and tumor stage at diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11,24</span></a> Diagnostic difficulties and slow growth are common in acral lentiginous melanoma and Bowen disease and in well-differentiated SUSCC. High mortality rates (30%-40% at 5 years) have been reported in some series of SUM.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2,22,26</span></a> By comparison, SUSCC exhibits particularly benign behavior. In the 2 largest series of SUSCC to date, comprising 104 patients, there were no cases of metastasis or death.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6,8</span></a> Based on data in the literature up to 2013, there have been just 10 cases of metastasis and 3 deaths due to SUSCCC.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">There are no clear recommendations on the surgical management of MSUTs.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6,13</span></a> SUM is not mentioned in the European Society for Medical Oncology<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">27</span></a> or the Scottish Intercollegiate Guidelines Network guidelines.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a> While it is mentioned in the American Academy of Dermatology (2011)<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">29</span></a> and National Comprehensive Cancer Network<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a> guidelines, the recommendations are limited to preoperative biopsy. The only guidelines (currently being revised) that offer guidance on the management of SUM are the Australian ones (2008).<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">31</span></a> These recommend adjusting the surgical margins to Breslow depth where possible, and mention the possibility of partial amputation at the level of the proximal joint located closest to the melanoma. The guidelines, published in 2008, state that “functional” amputation may be considered for subungual melanoma, as the little evidence available does not show advantages for radical amputation.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The general lack of recommendations on the surgical management of MSUTs contrasts with reports over the last decade of more conservative techniques than conventional amputation being used to treat MSUTs (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). The effectiveness of the different surgical modalities<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">13,25</span></a> and their influence on overall survival,<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5,6,17</span></a> however, are still a topic of debate, partly because of the absence of large series and the shortage of multicenter studies. Classic amputation, which can vary in terms of its completeness,<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2,26</span></a> can cause functional problems, poor cosmetic outcomes, and even psychological problems.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a> Amputation of the thumb has been associated with a 10% loss of function when performed at the interphalangeal joint but a 40% loss when performed at the metacarpophalangeal joint<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5,7,32</span></a> due to the shortening and deinsertion of the distal flexor tendon, which can make it difficult to pick up or grasp small objects.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a> In addition, patients may experience loss of sensation in the amputated area, causing interference with certain activities of daily living.</p><p id="par0095" class="elsevierStylePara elsevierViewall">It has been known since the 1990s that more extreme amputation does not offer any benefits in terms of recurrence or survival in SUM.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2,33–35</span></a> This finding led to the idea that functional surgery consisting of wide local excision with en bloc removal of the nail unit, without bone amputation, could be an effective alternative. In 2004, Moherle et al.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a> published a series of 62 SUMs, half of which were treated with amputation and half of which were treated with WLE of the nail unit. They found no differences between the groups for disease-free or overall survival, and there were just 2 local recurrences in the WLE group. Of interest was the use of 3-dimensional histology to check for tumor-free excision.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The results for the series identified in the literature search (<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>) show that 243 SUMs and 103 SUSCCs were treated by functional surgery consisting of WLE of the nail unit. Most of the MSUTs were in situ, thin, or minimally invasive and WLE produced excellent functional and cosmetic outcomes, without compromising prognosis. There were very few recurrences and they were mainly local. The local recurrence rate for SUSCCs was 8.7% and there were no metastases or deaths in the 103 patients analyzed. The local recurrence rate for SUM was 4.9% (12/243). The rate for other types of recurrence was just 4% (2 satellite and 8 lymph node metastases). Most of the tumors were in situ tumors or tumors with a Breslow depth of less than 1<span class="elsevierStyleHsp" style=""></span>mm. Just 30 tumors treated with WLE had a Breslow thickness of over 1<span class="elsevierStyleHsp" style=""></span>mm. The procedure in all cases consisted of en bloc excision of the nail unit for histopathologic examination with recommended surgical margins of 5<span class="elsevierStyleHsp" style=""></span>mm to 10<span class="elsevierStyleHsp" style=""></span>mm. Excision may<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">11</span></a> or may not<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a> include the periosteum and neither option appears to affect surgical or survival outcomes. Circumferential and dorsal advancement of the lateral and distal margins (paronychial advancement flap) reduces the size of the surgical defect, facilitating graft repair. In the earliest reports of WLE of the nail unit, surgical wounds were left to heal by secondary intention,<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">10</span></a> but it is now possible to use skin replacement systems (INTEGRA).<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a> Both options would be favored when the periosteum is excised or when doubts about the involvement of margins arise during surgery. When WLE of the nail unit first emerged, tumor clearance was checked with Mohs micrographic surgery<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">10</span></a> or 3-dimensional histology.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a> Now, however, it is not clear whether these techniques are useful for nail lesions, particularly in cases of incomplete nail excision, as the anatomic complexity of the folds makes it difficult to interpret findings.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6,9</span></a> Whatever the case, meticulous histology is required to ensure complete excision.</p><p id="par0105" class="elsevierStylePara elsevierViewall">There is an interesting discussion about the short distance between the nail matrix and the bony ridge, which is just 0.9<span class="elsevierStyleHsp" style=""></span>mm according to 1 cadaveric study.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a> Some authors have argued that this short distance is the main limiting factor for WLE versus amputation in the case of invasive (not noninvasive) tumors.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a> That said, an anatomic study of 30 amputation specimens from patients with invasive SUM found no bone involvement in 14 SUMs with a Breslow depth shorter than 4<span class="elsevierStyleHsp" style=""></span>mm and bone involvement in just 4 of the 16 SUMs with a Breslow depth of over 4<span class="elsevierStyleHsp" style=""></span>mm.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a> The authors concluded that functional surgery with WLE of the nail unit was feasible for intermediate-thickness tumors up to 4<span class="elsevierStyleHsp" style=""></span>mm. Our literature review (summarized in <a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>) clearly suggests that functional surgery with WLE is favored over amputation for noninvasive (in situ) or minimally invasive (<<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm) MSUTs.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6,16</span></a> Its indication for thicker lesions is less clear,<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5,22</span></a> but it has been used for both SUM and SUSCC without other poor prognostic factors and for patients who have refused amputation.<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a> Local recurrence rates are low in SUSCC (8.7%) and SUM (4.9%). Of the 103 SUSCCs treated with WLE of the nail unit in the literature, there were no cases of regional recurrence or mortality. In the case of SUM, none of the patients with a tumor with a Breslow depth of less than 1<span class="elsevierStyleHsp" style=""></span>mm developed regional metastasis or died. Like other authors,<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">3,5</span></a> we believe that the potential for metastasis depends on known risk factors (Breslow depth, ulceration, sentinel lymph node biopsy positivity) and not on the aggressiveness of the local surgery. The surgical approach should be sufficient to ensure complete removal of the tumor. In this regard, en bloc WLE of the nail unit, without amputation, should be an attractive option for a large proportion of patients. Tumors treated with limited resection or tumorectomy have a greater risk of recurrence and subsequent spread if remnant tumor is detected late. Tumorectomy in MSUTs produces margins that are difficult to examine histologically and it can also leave nail remnants with worse cosmetic outcomes than en bloc excision (WLE). In the case of thicker tumors (Breslow depth ><span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm), functional surgery consisting of WLE of the nail unit is feasible (although opinions are more divided on this) and carries a lower risk in SUSCC<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> than in SUM.<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">8,23</span></a> Amputation at the most distal point possible should be reserved for invasive tumors with bone or joint involvement, recurrent lesions, and lesions with a Breslow depth of over 4<span class="elsevierStyleHsp" style=""></span>mm.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">3,5,6</span></a> In the case of SUMs with an intermediate thickness (1-4<span class="elsevierStyleHsp" style=""></span>mm), the risks and benefits of functional surgery with WLE of the nail unit should be discussed with the patient, and if it is decided to go ahead, detailed histologic examination of the margins is essential.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">3,5,11</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Complications of WLE of the nail unit include wound infection, inclusion cysts, nail spicules, joint stiffness, reactive hyperkeratosis, pain and/or digital hypersensitivity to mild trauma, hypersensitivity to cold, and loss of fine-touch sensation.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">1,2,20</span></a> These adverse effects are well tolerated and, as our findings also show, have little or no effect on quality of life.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">1,20</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The limitations of our study include its retrospective design, the small number of cases included, and the analysis of 2 tumors that require similar surgical treatment due to their location but have different origins and biologic behavior. Notable strengths include the detailed individual study of patients and our extensive literature review. Because MSUTs are so uncommon, it would be interesting to perform multicenter studies and/or create registries to compile a sufficient number of cases to better define and standardize indications.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0120" class="elsevierStylePara elsevierViewall">Based on the evidence available for MSUTs, functional surgery consisting of WLE of the nail unit is the treatment of choice for SUSCCs without bone involvement and for noninvasive or thin (Breslow depth <<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm) SUMs. The data from our series and the literature indicate that WLE of the nail unit is associated with low recurrence and offers better functional and cosmetic outcomes than amputation. It can be considered in patients with intermediate-thickness SUMs (1-4<span class="elsevierStyleHsp" style=""></span>mm), but it should always be followed by meticulous histologic examination of the surgical margins to ensure excision completeness. Amputation, by contrast, would appear to be the treatment of choice for SUSCCs with bone involvement, very thick SUMs (><span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>mm), and recurrent tumors.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of Interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1089654" "titulo" => "Graphical abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:3 [ "identificador" => "xres1089656" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0010" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0015" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 2 => array:2 [ "identificador" => "xpalclavsec1033059" "titulo" => "Keywords" ] 3 => array:3 [ "identificador" => "xres1089655" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes y objetivos" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Conclusiones" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1033058" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "WLE of the Nail Unit: Surgical Technique (Figs. 1-3)" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Review of the Literature" ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of Interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-03-24" "fechaAceptado" => "2018-05-23" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1033059" "palabras" => array:3 [ 0 => "Subungual melanoma" 1 => "Subungual squamous cell carcinoma" 2 => "Functional surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1033058" "palabras" => array:3 [ 0 => "Melanoma subungueal" 1 => "Carcinoma epidermoide subungueal" 2 => "Cirugía funcional" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Background and objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Amputation is the conventional treatment for malignant subungual tumors (MSUTs), namely, subungual squamous cell carcinoma (SUSCC) and subungual melanoma (SUM). Functional surgery consisting of wide local excision (WLE) of the nail unit can preserve function without modifying prognosis in such cases. We present a series of MSUTs treated with WLE of the nail unit, describe the technique, and review its indications.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Retrospective observational study of MSUTs treated with WLE of the nail unit between 2008 and 2017. The technique consisted of en bloc supraperiosteal excision of the nail unit with a margin of 5<span class="elsevierStyleHsp" style=""></span>mm followed by repair with a full-thickness graft.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Eleven MSUTs were treated in the study period: 7 SUMs (4 in situ; mean thickness, 1.17<span class="elsevierStyleHsp" style=""></span>mm; range, 0-4<span class="elsevierStyleHsp" style=""></span>mm) and 4 SUSCCs (mean thickness, 3.4<span class="elsevierStyleHsp" style=""></span>mm; range, 1.6-6<span class="elsevierStyleHsp" style=""></span>mm). WLE of the nail unit was performed in 9 patients and amputation in 2 patients with invasive SUM. Mean follow-up was 39 months (range, 12-96 months) and no local or regional recurrences were detected. One of the 2 patients who underwent amputation developed metastasis to the brain and died. In our review of the literature, we identified 5 series of patients with SUSCC treated with WLE of the nail unit (105 patients) and 14 series of patients with SUM (243 patients). Based on an analysis of these cases and ours, it would appear that WLE of the nail unit is associated with a very low rate of local recurrence (<<span class="elsevierStyleHsp" style=""></span>7%) and offers better functional and cosmetic outcomes than amputation.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">WLE of the nail unit is the treatment of choice for SUSCC without bone involvement and for thin noninvasive SUM (Breslow depth <<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm). It is also feasible in intermediate-thickness SUMs when detailed histologic examination of the margins confirms complete resection. Amputation, by contrast, is the treatment of choice for SUSCCs with bone involvement, very thick SUMs (><span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>mm), and recurrent tumors.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0010" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0015" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes y objetivos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El tratamiento clásico de los tumores malignos subungueales (TMSU), carcinoma epidermoide (CESU) y melanoma (MSU), es la amputación. La cirugía funcional del aparato ungueal (CFAU) puede preservar la función sin modificar el pronóstico. Presentamos nuestra serie de TMSU manejados con CFAU, describimos la técnica y revisamos sus indicaciones.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Material y métodos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional retrospectivo de TMSU tratados con CFAU entre 2008 y 2017, con exéresis supraperióstica en bloque del aparato ungueal, margen a 5<span class="elsevierStyleHsp" style=""></span>mm, y cierre con injerto de piel total.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se trataron 11 TMSU, de los cuales 7 fueron MSU (4 in situ, espesor medio: 1,17<span class="elsevierStyleHsp" style=""></span>mm; rango: 0-4<span class="elsevierStyleHsp" style=""></span>mm) y 4 CESU (espesor medio: 3,4<span class="elsevierStyleHsp" style=""></span>mm; rango: 1,6-6<span class="elsevierStyleHsp" style=""></span>mm). Se realizó CFAU en 9 casos y 2 amputaciones en sendos MSU invasivos. El seguimiento medio fue 39 meses, con un rango de 12-96 meses. No hubo recidivas locales ni regionales. Solo un caso —una de las 2 amputaciones—tuvo metástasis (cerebrales) y muerte.</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La revisión de la literatura de CFAU en TMSU mostró 5 series (103 pacientes en total) con CESU y 14 series (243 pacientes en total) con MSU. El análisis de nuestros casos y de los casos publicados muestra muy escasas recurrencias locales (<<span class="elsevierStyleHsp" style=""></span>7%), y mejores resultados funcionales y estéticos frente a la amputación.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La CFAU es de elección en CESU sin afectación ósea y MSU no invasivo o delgado (Breslow <<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm). Es factible en MSU de grosores intermedios siempre con detallado estudio histológico de márgenes que asegure una resección completa. Por el contrario, en CESU con afectación ósea, MSU muy grueso (>4<span class="elsevierStyleHsp" style=""></span>mm) o recurrencias, la amputación debe ser habitualmente de elección.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes y objetivos" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Please cite this article as: Flores-Terry M, Romero-Aguilera G, Mendoza C, Franco M, Cortina P, Garcia-Arpa M, et al. Cirugía funcional en tumores malignos subungueales. Serie de casos y revisión de la literatura. Actas Dermosifiliogr. 2018;109:712–721.</p>" ] ] "multimedia" => array:10 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 681 "Ancho" => 1250 "Tamanyo" => 164319 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Case 1. Functional surgery with wide local excision of the nail unit in a patient with amelanotic subungual melanoma in situ and complete onychodystrophy of the left index finger. Results after 2 years.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 792 "Ancho" => 1250 "Tamanyo" => 156256 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Case 10. Functional surgery with wide local excision of the nail unit in a patient with a moderately differentiated subungual squamous cell carcinoma with a thickness of 4<span class="elsevierStyleHsp" style=""></span>mm and extensive onychodystrophy of the right thumb. Result after 6 months.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 759 "Ancho" => 1250 "Tamanyo" => 176358 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Case 11. Functional surgery with wide local excision of the nail unit in a patient with a moderately differentiated subungual squamous cell carcinoma with a thickness of 6<span class="elsevierStyleHsp" style=""></span>mm on the first toe of the left foot. Note the excrescent tumor in the area of the onychodystrophy. Result after 4 months.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1245 "Ancho" => 2083 "Tamanyo" => 294752 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Photographs of the 7 subungual melanomas in our series.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1763 "Ancho" => 2083 "Tamanyo" => 367637 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Photographs of the 4 subungual SCCs. MD indicates moderately differentiated; SCC, squamous cell carcinoma; WD, well-differentiated.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1482 "Ancho" => 1521 "Tamanyo" => 225638 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Flow chart showing the different stages in the literature search for publications on functional surgery with WLE of the nail unit in MSUTs. WLE indicates wide local excision; MSUT, malignant subungual tumor; SUM, subungual melanoma; SUSCC, subungual squamous cell carcinoma.</p>" ] ] 6 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: AMP, amputation; F, female; HK, hyperkeratosis; M, male; ND, nail dystrophy; SUM, subungual melanoma; SUSCC, subungual squamous cell carcinoma; WLE, wide local excision of nail unit.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex/Age, y \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis, y \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Location \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical Presentation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time Since Onset, mo \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of MSUT \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Breslow Depth \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">WLE/Amputation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recurrence/Death \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Follow-up, mo \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F/50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Second left finger \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Complete ND, amelanotic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SUM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In situ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">WLE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No/no \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F/65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Third right finger \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diffuse melanonychia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SUM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In situ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">WLE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No/no \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F/77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fourth right toe finger \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Subungual pigmented tumor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SUM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4<span class="elsevierStyleHsp" style=""></span>mm, ulcerated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AMP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Brain metastasis/yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31 (death) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M/78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left thumb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Longitudinal melanonychia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SUM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In situ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">WLE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No/no \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F/54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Second right finger \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Longitudinal melanonychia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SUM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In situ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">WLE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No/no \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M/55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2016 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">First right toe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Longitudinal melanonychia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SUM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.38<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">WLE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No/no \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M/52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2017 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">First left toe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Complete ND, extensive melanonychia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">120 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SUM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.8<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AMP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No/no \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M/61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">First left toe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HK/complete ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SUSCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">WLE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No/no \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">72 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M/45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">First right toe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HK/lateral ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SUSCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.5<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">WLE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No/no \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M/59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right thumb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HK/central ND, onycholysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SUSCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">WLE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No/no \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F/81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2017 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">First left toe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tumor outgrowth, ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SUSCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">WLE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No/No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1862896.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Epidemiologic and Clinical Characteristics and Outcomes in Patients With Malignant Subungual Tumors.</p>" ] ] 7 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: LR, local recurrence; NS, not specified; WLE, wide local excision of nail unit.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Authors, y (Country) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study Period \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total Tumors \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Noninvasive (In Situ) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Invasive \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean Breslow Depth, mm (Range) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Amputation (LR) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Limited Excision (LR) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complete WLE (LR) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Metastasis/Mortality \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean Follow-up, mo \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Topin-Ruiz et al., 2017 (France)<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2000-2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0/0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">79 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lecerf et al., 2013 (Belgium)<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1995-2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2,47 (1.5-8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0/0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40 (4-177) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dalle et al., 2007 (France)<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">9</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2000-2005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.1 (0.3-2.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1/1<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31 (10-90) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lazar et al., 2005 (France)<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1995-2000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0/0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">De Berker et al., 1996 (UK)<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">10</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1988-1994 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0/0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1862897.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Data shown as numbers unless otherwise specified.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">In 20 patients biopsy only and other treatments, such as 5<span class="elsevierStyleHsp" style=""></span>fluorouracil, bleomycin, imiquimod, and photodynamic therapy.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Original Series of Subungual Squamous Cell Carcinoma Including Tumors Treated With Functional Surgery Consisting of WLE of the Nail Unit.<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></p>" ] ] 8 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: AMP, amputation; BD, Breslow depth; L, local; N, nodal; NS, not specified; OS, overall survival; Rc, recurrence; S, systemic; T, transit; WLE, functional surgery with wide local excision of nail unit.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Authors, y (Country) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study Period \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total Cases \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">In situ \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">><span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean BD, mm \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AMP \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">WLE \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Rc (BD<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>1 mm) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Rc (BD<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>1 mm) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Deaths \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Follow-up, (mo) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Ogata et al., 2017 (Japan)<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">11</span></a></td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">200-13</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">148</td><td class="td" title="table-entry " align="left" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">OS<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a></td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">112</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">112 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lee et al., 2017 (Korea)<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2011-16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">17</td><td class="td" title="table-entry " align="left" valign="top">0.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>T \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nakamura et al., 2015 (Japan)<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1996-2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sinno et al., 2015 (United States)<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2003-2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anda et al., 2015 (Mexico)<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">14</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1989-2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lecerf et al., 2014 (Belgium)<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">15</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1998-2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haddock et al., 2012 (United States)<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2003-2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sureda et al., 2011 (France)<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2004-2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Cohen et al., 2008 (United States)<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a></td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">1992-2004</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">49</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3<span class="elsevierStyleHsp" style=""></span>T, 4<span class="elsevierStyleHsp" style=""></span>N, 4<span class="elsevierStyleHsp" style=""></span>S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">OS<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">38</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rayatt et al., 2007 (UK)<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">94 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lazar et al., 2005 (France)<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1995-2000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High et al., 2004 (United States)<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1997-2002 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glat et al., 1996 (United States)<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1982-1995 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">83 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Moehrle et al., 2003 (Germany)<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a></td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">1980-1999</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">62</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">6</td><td class="td" title="table-entry " align="left" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">2<span class="elsevierStyleHsp" style=""></span>LN, 1<span class="elsevierStyleHsp" style=""></span>T, 7<span class="elsevierStyleHsp" style=""></span>LN, 1<span class="elsevierStyleHsp" style=""></span>S</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">11</td><td class="td" title="table-entry " align="left" valign="top">55 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">6</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">2<span class="elsevierStyleHsp" style=""></span>LN, 1<span class="elsevierStyleHsp" style=""></span>T, 7<span class="elsevierStyleHsp" style=""></span>LN, 1<span class="elsevierStyleHsp" style=""></span>S</td><td class="td" title="table-entry " align="left" valign="top">54 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1862895.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Data shown as numbers unless otherwise specified.</p>" ] 1 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Data only on aggregate morality such as overall survival.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Original Series of Subungual Melanoma Including Tumors Treated With Functional Surgery Consisting of WLE of the Nail Unit.<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a></p>" ] ] 9 => array:5 [ "identificador" => "fig0035" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 797 "Ancho" => 1333 "Tamanyo" => 104944 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:38 [ 0 => array:3 [ "identificador" => "bib0195" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Malignant nail tumors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 20 | 5 | 25 |
| 2024 Octubre | 130 | 47 | 177 |
| 2024 Septiembre | 152 | 38 | 190 |
| 2024 Agosto | 160 | 66 | 226 |
| 2024 Julio | 128 | 46 | 174 |
| 2024 Junio | 135 | 36 | 171 |
| 2024 Mayo | 101 | 51 | 152 |
| 2024 Abril | 100 | 33 | 133 |
| 2024 Marzo | 127 | 33 | 160 |
| 2024 Febrero | 228 | 41 | 269 |
| 2024 Enero | 163 | 38 | 201 |
| 2023 Diciembre | 137 | 32 | 169 |
| 2023 Noviembre | 196 | 32 | 228 |
| 2023 Octubre | 184 | 45 | 229 |
| 2023 Septiembre | 157 | 46 | 203 |
| 2023 Agosto | 133 | 35 | 168 |
| 2023 Julio | 157 | 49 | 206 |
| 2023 Junio | 96 | 30 | 126 |
| 2023 Mayo | 219 | 35 | 254 |
| 2023 Abril | 207 | 35 | 242 |
| 2023 Marzo | 228 | 37 | 265 |
| 2023 Febrero | 149 | 34 | 183 |
| 2023 Enero | 122 | 33 | 155 |
| 2022 Diciembre | 89 | 33 | 122 |
| 2022 Noviembre | 60 | 27 | 87 |
| 2022 Octubre | 65 | 42 | 107 |
| 2022 Septiembre | 92 | 45 | 137 |
| 2022 Agosto | 90 | 49 | 139 |
| 2022 Julio | 97 | 56 | 153 |
| 2022 Junio | 39 | 31 | 70 |
| 2022 Mayo | 130 | 57 | 187 |
| 2022 Abril | 172 | 40 | 212 |
| 2022 Marzo | 185 | 66 | 251 |
| 2022 Febrero | 180 | 38 | 218 |
| 2022 Enero | 173 | 41 | 214 |
| 2021 Diciembre | 143 | 46 | 189 |
| 2021 Noviembre | 155 | 59 | 214 |
| 2021 Octubre | 88 | 76 | 164 |
| 2021 Septiembre | 73 | 48 | 121 |
| 2021 Agosto | 88 | 65 | 153 |
| 2021 Julio | 70 | 44 | 114 |
| 2021 Junio | 60 | 36 | 96 |
| 2021 Mayo | 53 | 64 | 117 |
| 2021 Abril | 90 | 107 | 197 |
| 2021 Marzo | 82 | 53 | 135 |
| 2021 Febrero | 62 | 43 | 105 |
| 2021 Enero | 62 | 47 | 109 |
| 2020 Diciembre | 70 | 52 | 122 |
| 2020 Noviembre | 45 | 38 | 83 |
| 2020 Octubre | 44 | 28 | 72 |
| 2020 Septiembre | 40 | 31 | 71 |
| 2020 Agosto | 46 | 34 | 80 |
| 2020 Julio | 40 | 32 | 72 |
| 2020 Junio | 42 | 41 | 83 |
| 2020 Mayo | 50 | 36 | 86 |
| 2020 Abril | 17 | 16 | 33 |
| 2020 Marzo | 32 | 18 | 50 |
| 2020 Febrero | 1 | 1 | 2 |
| 2019 Mayo | 1 | 0 | 1 |
| 2019 Marzo | 1 | 0 | 1 |
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